Initial Referral Form
Form for volunteers or Community Program Coordinator to gather preliminary information for potential Jumpstart assistance
Email address *
Head of Household (First and Last Name) *
Your answer
Head of Household (Main Telephone Number) *
Your answer
Location (City, State) *
Your answer
Names and Ages of all Members of the Household *
Your answer
Origin (City and Country) *
Your answer
Transit Country (If Applicable) E.g. Turkey, Jordan, Lebanon, Egypt, etc.
Your answer
Arrival Date in the U.S. *
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US Registration and Identification is (Check all that apply) *
Occupation for Heads of Household (If anyone is unemployed, please indicate): *
Your answer
Referral By (Name and/or Organization and Best Method of Contact): *
Your answer
Main Support of Requested Assistance (Please Check all that Apply): *
Required
Car/Car Insurance
Does this family need this car/car insurance support because they are actively looking for work/employed? Please explain in 2-4 sentences
Your answer
Does this family live in an area without any transportation support or public transportation?
Does this family already have a vehicle? *
Vocational Training/Certification
Does this family need this vocational training support because they are actively looking for work/employed? Please explain in 2-4 sentences
Your answer
What will this training/certification provide for the family (type) and for how long? Please explain in 2-4 sentences
Your answer
Emergency Support
Please provide a brief background of the family and the emergency situation
Your answer
What is the kind of Emergency Support (type) requested and for how long? Please explain in 3-4 sentences
Your answer
After the support is provided, do you believe this family will be able to use this to help themselves after the initial assistance? Please explain
Your answer
Has this family received any other community support towards this and other similar situations?
Your answer
Other
Please indicate that what is being requested (Youth, Disability, Referral Request, etc) and why (3-4 sentences)
Your answer
Is this support already being provided by local community members?
Family Concerns
Please have the family explain their situation in their own words, what the assistance will provide for their family towards acclimation and community engagement, if applicable
Your answer
Additional Comments
Please indicate any special notes Karam Foundation should take note of for this family
Your answer
Signature (Name and Date)
Electronic Signature *
Your answer
*
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